DERMAL AND DERMAL AND SUB DERMAL LESIONSSUB DERMAL LESIONS

Dr M Kanagavel DNB Surgery MRCS EdinDr M Kanagavel DNB Surgery MRCS Edin

Faculty and ConsultantFaculty and ConsultantDepartment of General, GI and Minimal Access SurgeryDepartment of General, GI and Minimal Access Surgery(Accredited by The National Board of Examinations)(Accredited by The National Board of Examinations)St Isabel HospitalSt Isabel HospitalChennai – 600 004Chennai – 600 004

This Presentation:• Overview of Dermal and Subdermal Lesions• Define the Lesion• Types:

– Benign Nodular Lesions– Papules and Plaques– Pigmented Lesions– Subepidermal Lesions– Benign Dermatoses– Malignant Lesions

• Surgical Treatment and Biopsy• Surveillance and Follow-up

The Microscopic Architecture

Gross morphologic terms

• Blister - Nonspecific term for fluid-filled lesion (see vesicle or bulla)

• Bulla - Fluid-filled lesion >5 mm in greatest dimension

• Erosion* - Loss of epidermis• Excoriation - Lesion of traumatic nature with

epidermal loss in a generally linear shape• Lichenification * - Grossly thickened, leathery,

hyperpigmented skin with hyperkeratosis and deep,

Gross morphologic terms

• Macule - Flat circumscribed area demarcated by color from surrounding tissue

• Nodule - Solid raised discrete lesion >5 mm in both diameter and depth

• Onycholysis – Separation of the nail from the nailbed

• Papule - Solid raised discrete lesion ≤5 mm• Pedunculated - Attached to its base by a stalk-

like structure• Plaque - Flat but elevated area, usually >5 mm

Gross morphologic terms

• Pustule - Small pus-filled elevated area of the skin with discrete borders

• Ulceration* - Loss of epidermis with partial-to-complete loss of dermis

• Seborrheic - Related to excessive secretion of sebum• Sebum - Thick, greasy substance secreted by

sebaceous glands that consists of fat and cellular debris• Sessile - Attached directly to the skin by a broad base;

not pedunculated• Vesicle - Fluid-filled lesion ≤5 mm

Skin Lesions

Histologic definitions

• Acantholysis - Dissolution of intercellular integrity with fragmentation of epidermis

• Acanthosis - Hyperplasia of epidermal layer• Dyskeratosis - Abnormal keratinization occurring

prematurely in cells below the stratum granulosum

• Erosion* - Loss of epidermis• Exocytosis - Infiltration of epidermis by

inflammatory cells

Histologic Definitions

• Hyperkeratosis (keratosis) - Thickening of the stratum corneum (the outermost layer of the epidermis) with excess abnormal keratin

• Lichenification * - Hyperplasia of all compartments of the epidermis with acantholysis and papillomatosis

Histologic Definitions

• Papillomatosis - Hyperplasia of the papillary dermis and lengthening and/or widening of the dermal papillae

• Parakeratosis - Persistence of the nuclei within the cells of the stratum corneum of the epidermis as seen in psoriasis

• Spongiosis - Edema limited to the epidermis• Ulceration* - Loss of epidermis with variable

partial-to-complete loss of dermis

Definitions

• Acral - Related to the extremities and the more distal parts of the body

• Actinic – Relating to biochemical changes in the skin produced by sunlight energy from both the visible and ultraviolet rays

History

• Duration• Mode of Onset• Associated Symptoms

– Pain• Nature• Site• Time of Onset

– Progression– Exact Site

History

– Systemic Symptoms– Presence of Other lumps– Secondary Changes– Impairment of Function– Recurrence– Body Weight– Personal Hsitory

Physical Characteristics

• Characteristics outside of the lesion

• Physical characteristics of the lesion

• Histologic characteristics of the lesion

Physical Examination - Inspection

• Site• Size• Shape and Extent• Surface• Edge• Number• Pulsation• Peristalsis• Surrounding Structures

Examination - Palpation

• Signs of Inflammation• Site• Size• Shape and Extent• Surface• Edge• Consistency• Number• Pulsation / fluctuation

• Fluid Thrill• Translucency• Cough Impulse• Reducibility• Compressibility• Fixity to Overlying Skin• Relation to Surrounding

Structures• Pressure Effect• Examination of nearby

joints

Examination

• Auscultation

• Percussion

Characteristics outside the lesion

• The characteristics outside of the lesion refer to the attributes and condition of the patient beyond the skin lesion itself.

Papules and Plaques

Acrochordon

• Soft, common, benign, usually pedunculated neoplasm

• It is usually skin colored or hyperpigmented,

• surface nodules or papillomas

• 2-5 mm in diameter, although larger measure up to 5 cm

• Neck and the axillae, but any skin fold, including the groin, may be affected.

Keratoacanthoma

• They are hemispheric shaped with a keratin-filled crater and overhanging edges

Pyogenic Granuloma

• is a rapidly proliferating solitary lesion of mostly disorganized vascular growth known for its bleeding tendencies.

• Also known as a cutaneous ectasia,

• it is commonly associated with minor previous trauma to the area

Sebaceous Horn – Cornu cutaneum

• is a skin lesion made of compacted keratin that forms an exophytic conical projection

• Actinic keratoses, Seborrheic keratoses, benign verrucae, inverted follicular keratoses, and sqaumous cell carcinoma

Keloid• fibrotic, papular lesions that

usually occur as an aberrant healing response to cutaneous injuries, such as acne, trauma, surgery, and piercing

• earlobes, chest, lower legs, upper back, and jaw line.

• unlike hypertrophic scars, grow beyond the borders of the original scar.

• pruritus, pain, and, occasionally, a burning sensation.

Seborrhiec keratosis

• greasy appearance and prevalence in regions of the body with a high concentration of sebaceous glands (ie, face, shoulder, chest, back).

Subepidermal Lesions

Sebaceous Cyst

• Blocked Sweat Gland

• Punctum

• Skin at the summit not pinchable

Dermoid Cyst

Retention Cyst

Lipoma

LIPOMA

Neurofibroma

Pyogenic Granuloma

Traumatic

• Hematoma

• Implantation Dermoid

Inflammatory

• Erysipelas

• Cellulitis

Abscess

• Pyogenic

• Pyemic

• Cold

• Furuncle Carbuncle

• Carbuncle

Moles

• Hairy Mole

• Non Hairy Mole

• Blue Naevus

• Junctional Naevus

• Compound Naevus

• Juvenile Mole

• Hutchisons Freckle (Lentigo)

Melanocytic Naevus

Neoplasm - Malignant

• Basal Sell Ca – Rodent ulcer

Wart

• Overgrowth of Skin with hyperkeratosis

Callosity / Corn

Bowen’s Disease

• Velvetty, flat lesions

• Clear margin

• Premalignant

• Ca in situ

Vascular Lesions

• Hemangiomas,

• Kaposiform hemangioendothelioma (KHE),

• Tufted angiomas (TA),

• Pyogenic granulomas,

• Hemangiopericytomas, and other rare lesions.

Vascular Tumor/Infantile HemangiomaVascular Malformations

• Proliferative

• 30% visible at birth

• 70% become apparent during first few weeks of life

• Female to male ratio 3:1

• Rapid postnatal growth followed by slow involution

• Endothelial cell proliferation• Increased mast cells

• No coagulation abnormalities• High percentage respond dramatically to corticosteroid treatment in 2 to 3

weeks• Immunopositive for biologic markers (including GLUT1)

Hemangiomas

Vascular Malformations

• Congenital malformations of capillaries, veins, lymphatic vessels, or arteries.

• They may also exist as a combination of different types of vessels (eg, the arteriovenous malformation).

Classification

• These malformations may further be

– High-flow

– Low-flow lesions based on the vessel type.

Lymphatic Classification

• The lymphatic lesions may be further divided into macrocystic and microcystic based on the size of the cystic components within the lesion.

Vascular Malformations

• Vascular malformations are congenital, meaning that they are present at birth.

• Most are diagnosed during infancy, although some are noticed later in childhood.

• In the case of a lymphatic malformation that presents after viral upper respiratory infection.

Vascular Malformation• Congenital abnormality with proportional growth

• No gender predilection

• May expand secondary to sepsis, trauma, or hormonal changes

• Normal endothelial cell turnover

• Normal mast cell count

• Do not involute

• Localized consumptive coagulopathy possible• Low-flow: phleboliths, ectatic channels• High-flow: enlarged, tortuous vessels with arteriovenous shunting• No response to corticosteroids or antiangiogenic agents• Immunonegative for hemangioma biologic markers

Venous Malformations

• Composed of ectatic, poorly organized venous channels that have normal endothelium and lack the normal smooth muscle architecture that usually surrounds veins.

• Malformations are low-flow lesions.

Lymphatic Malformations

• Present at birth and lined by nonproliferating endothelium.

• They may occur anywhere in the body, although the head and neck region is most commonly affected.

• Lymphatic malformations are low-flow lesions and may exist as combinations of lymphatic and venous vessels, in which case they are termed venous-lymphatic malformations

Arteriovenous malformations

• Arteriovenous malformations (AVMs) are high-flow lesions that allow shunting of blood from the arterial system directly into the venous system.

• It is thought that they are residual from failure of primitive vascular communications to obliterate.

• In addition, these lesions share the ability with other vascular malformations to expand rapidly with infection, trauma, or hormonal disturbance.

Investigations

• General

• Specific

• FNA

• Exfoliative Cytology

• Skin Testing

• Ultrasound

• CT

• Biopsy– Drill / Punch– Incisional– Excisional– Punch

Planning Excision

Vascular Lesions

Welcome to

5th ISABEL SURGICAL REVISION COURSE 2013

24th Sunday 2013

St Isabel Hospital Auditorium

in alliance with ASI – Chennai City Section